Lutz Jr, Johannes 09/19/ 0'11 1'S:53 15184 '3bb::;'..e 14 Wl
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Trans' Permit
Vitel iew Records Section • N _-"r_ _'
! Name First Middle Last ' Sex
Johannes Lutz, Jr, Male
Date of Death ' Age ' if Veteran of U.S.Armed Forces,
} ! September 17, 2011 41 ! War or Dates No —,
!I Place of Death I Hospital,Institution M
j City ,Town or villag_e City of Albany or Street Address Albany Medical Center Hospital
! l Manner of Death Natural Undetermined in
tLf� 123 Cause r— Accident El Homicide El Suicide ❑ Circumstances ❑ Investigation
to Medical Certifier Name �� Title
(41 Deborah Light MD
I Address
AMCH 43 New Scotland Avenue Albany, NY 122013
Death Certificate Filed 1 District Number I Register Number
City,Town or Village City of Albany 101 ; 1735
�—. Date -1 Cemetery or Crematory
j ! ❑Burial i September 20, 2011 I Pine View Crematory
0 Entombment r---
CD Cremation Address
Queensbury, NY
Date I Place Removed -1
I]g Li Removal Hold �__ _s__ ; and/or Held
and/or Address
t
Date ;` Point of
,Q Transportation Shipment
'tit)! 0 By Common 8 t7
Carrier estination
+
Q Disinterment
Date Cemetery Address _ _.,. �...._
❑ Date Cemetery Address
Reinterment
Permit issued To Reg stration Number
Name of Funeral Home Regan & Denny Funeral Home , 01443
Address �~Y
1 53 Quaker Road Queensbury, NY
II Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
}
Address
1tuj
�µ
il.Permission is hereby granted to dispose of the human remains desoripied above as indicat,d.
Date September 19, 2011 i 'r; i .71
Issued Registrar of Vital Statistics 9 at i e) `'�
•
District Number 101 Place w City of Albany, NY
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
Date of Disposition 1{Zo((1 Place of Disposition Plat CAM^{ orwi`-
iuu (address)
w
CL3 (section) (lot number) (grave number)
0
Z Name of Sexton or Person in 0 ones of Premises r tti S tM.to}
(please print)
j Signature _______ ift Title (QtM'rRISP.
(over)
DOH-1555(02/2004)